MEDICARE: LEANNE SULLIVAN M.A., LMHCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	MC 60398056	WA
2	101YM0800X	Mental Health Counselor	MC 60398056	WA
3	101YP2500X	Professional Counselor	MC 60398056	WA

General Provider Information

NPI Number	:	1073946083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANNE SULLIVAN M.A., LMHCA

Provider Business Mailing Address
First Line	:	4227 S MERIDIAN
Second Line	:	SUITE #C-576
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3603
Country	:	US
Telephone Number	:	253-474-7188
Fax Number	:	253-446-7137

Provider Business Practice Location Address
First Line	:	2832 S MERIDIAN
Second Line	:	SUITE 101
City	:	PUYALLUP
State	:	WA
Zip	:	98373-1447
Country	:	US
Telephone Number	:	253-474-7188
Fax Number	:	253-446-7137

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	08/13/2013

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